Early Extracorporeal Membrane Oxygenation After Pediatric Heart Transplant Improves Survival Over Delayed Support
John Thomas Kennedy, III, MD1, Kevin Kulshrestha, MD, MBE2, Jason W. Greenberg, MD2, Tanya Perry, DO2, David S. Cooper, MD, MPH2, Clifford Chin, MD2, David G. Lehenbauer, MD2, Farh Zafar, MD, MS2, David L. S. Morales, MD2.
1University of Cincinnati Medical Center, Cincinnati, OH, USA, 2Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Objective: Severe early graft dysfunction affects up to 10% of pediatric heart transplants (HTx), and ECMO is commonly used for management. This study compares the immediate versus delayed ECMO initiation.
Methods: Children <18-years-old who underwent HTx were identified from a combined UNOS/PHIS database. Patients were assigned to the immediate cohort if ECMO was initiated on POD0 or to the delayed cohort.
Results: 4,046 children were included; 325 (8.0%) required post-HTx ECMO. 218 (67%) were initiated on ECMO at HTx. Remaining patients started ECMO on POD1 (IQR: 1-9). Immediate ECMO patients were older and more likely to have received pre-operative ECMO. ECMO duration was similar between cohorts. Each day of ECMO was associated with an increase in absolute in-hospital mortality by 3.1% (R=0.83, p<0.001) and 3% (R=0.87, p<0.001) for immediate and delayed cohorts, respectively. Delayed ECMO had higher in-hospital mortality (44% vs 31%, RR: 1.7, 95%CI: 1.1-2.8) and worse 3-year survival (46% vs 58%, p=0.036). If discharged, 3-year survival was similar (86% vs 83%, p=0.48). Compared to a no ECMO cohort, propensity score matching demonstrated similar outcomes for the immediate cohort who survived to discharge (86% vs 91%, p=0.1) but not for the delayed cohort.
Conclusion: Post-HTx ECMO is associated with poor outcomes. However, immediate ECMO results in better outcomes than delayed initiation, suggesting immediate cannulation may be prudent if early graft dysfunction is a concern.
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